Duty to Assist Development Required:
Digestive System Fact Sheet 2
(Esophagus and Hiatal Hernia)
Several factors are considered when evaluating veteran’s claims for VA disability compensation benefits. Once service connection is established for disability compensation benefits, veterans may apply for an increased evaluation if they believe the disability has worsened in severity.
In order to assist with the processing of a veteran’s claim for increase, the following information is provided to assist you in documenting the disability’s current level of severity for evaluation purposes. Medical documentation should provide the following information for the digestive system:
1. Describe medical history (subjective complaints). Please comment on the following:
• Dysphagia – for solids and liquids (frequency and extent).
• Pyrosis, epigastric or other pain, including associated substernal or arm pain (frequency and severity).
• Hematemesis or melena (describe any episodes).
• Reflux or regurgitation (frequency); for regurgitation, contents.
• Nausea, vomiting (frequency, precipitants).
• Treatment – type, duration, response, side effects. If there is dilatation, give frequency.
• History of hospitalizations and surgery – reason or type of surgery, location and dates (if known).
• History of esophageal trauma.
• Effects of condition on occupational functioning and activities of daily living.
• History of neoplasm:
o Diagnosis and date of onset.
o Benign or malignant.
o Treatment, dates and response.
o Last date of treatment.
2. Describe objective findings. Address each of the following and fully describe current findings:
• General state of health.
• Nutrition, weight gain or loss.
• Signs of anemia.
3. Diagnostic and clinical tests:
• X-ray or endoscopic confirmation of obstruction, abnormal motility, esophagitis, reflux, etc.
• If there is a history of bleeding (past 12 months) or signs of anemia, obtain hemoglobin/hematocrit.
• Include results of all diagnostic and clinical tests.
4. Diagnosis:
• List diagnoses.
• With obstruction or spasm, is it amenable to dilatation?
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